Please fill out the below patient registration form or download a copy here and bring it with you to your first appointment.


Patient Details

Title

First Name

Last Name

Date of Birth


Address


Suburb

State

Postcode


Email Address

Mobile Phone

Home Phone

Work Phone


Medicare Details

Medicare Number

Ref Number next to name

Expiry Date


Parent/Carer Details If Patient is a Minor

First Name

Last Name

Date of Birth

Medicare Number


Next of Kin/Emergency Contact

Name

Relationship

Contact Number


Private Health Fund Details

Level of Cover

Private Health Fund Name

Private Health Fund Membership Number


Dept of Veterans Affairs Details

DVA Card

DVA Card Number

DVA White Card Approved Condition


Referring Doctor Details

Referring Doctor’s Name

Clinic Suburb

GP Name (if not referrer)

Clinic Suburb


SMS Appointment Reminder

Do you wish to receive appointment reminders via SMS?


Privacy Information

To enable the ongoing provision of care within this practice, and in keeping with the Privacy Act 1988 and Australian Privacy Principles (APPs), we wish to provide you with information on how your personal and health information may be used or disclosed.

WestsideENT collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs.

Your personal and health information will only be used for the purposes for which it is collected, or as otherwise permitted by law.


Consent

I have read the information above and understand the reasons why my information must be collected. I am also aware that WestsideENT has a Privacy Policy on handling patient information which is displayed on its website.

I consent to the use of my personal and health information by WestsideENT and other health providers involved in my medical care. I consent to the disclosure of my personal and health information by WestsideENT to other health providers directly or indirectly involved in my personal health care or medical treatment.

I give my consent to WestsideENT to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information, to WestsideENT as may be requested.



Medical Information

Medical Conditions (Please tick all that apply)
High Blood Pressure
Cardiac Bypass Surgery
Blood Clots / Pulmonary Embolism / DVT
Chronic lung disease/COPD
Stroke
Cardiac Stents
Asthma
Atrial Fibrillation
Heart Attack
TIA
Diabetes


Bleeding Disorders

Do you have a history of any bleeding diseases?

Is there a family history of any bleeding diseases?


Do you take any of these medications?

Aspirin
Eliquis (apixaban)
Anti-inflammatory drugs
eg neurofen, brufen, celebrex, voltaren
Pradaxa(dabigatran)
Plavix (clopidogrel)
Warfarin
Xarelto (riviroxaban)


Current Medications


Allergies



Smoking & Alcohol History

Smoking Status

No of years smoking

No of cigarette per day

Quit Date


Do you drink alcohol?

Drinks per week

Your Signature

Please prove you are human by selecting the Flag.



BOOK AN APPOINTMENT

Call us at 07 3202 4636

or